HomeMy WebLinkAbout4-18-38Certificate No. 2266
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Rosa Zamarripa Post Office Box 522, Fellsmere, FL 32948
(name) (address)
In and for consideration of the sum of $2,000.00 is entitled to full interment
rights in the Sebastian Municipal Cemetery for the following lot:
Unit 4, Block 18, Lot 38
of the Sebastian Municipal Cemetery,
as maintained on file in the records of the City Clerk
for use in accordance with the conditions, ordinances, resolutions, rules and
regulations prescribed therefore by the City of Sebastian.
CONVEYED THIS 6th day of August, 2010.
CITY OF, SEBASTIAN, FLORIDA
Al Minner
City Manager
ATTEST:
Sally A aio, MMC
C tv Clerk
Name D1,*Wj � N! � T /A �X 11'2 �
Unit
Block
Lot
Date of Mark -out ,e2 /j O
Date of Burial /y 116) Time
Name of Funeral Home Jr ��? �e� j Al
Authorized by
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Sep 04 2009 2:13PM COS CEMETERY 7722289927 p -2
FUNERAL DIRECTOR'S REQUEST TO CITY OF SEBASTIAN
FOR BURIAL OPENING IN SEBASTIAN MUNICIPAL. CEMETERY
h�«r ►file. -S
For information contact:
Kfp Kelso - Cemetery Sexton
Sebastian Mtrnicipat Cemetery wl
(772) 588.2545 �
City Clews Office
City Hatt, 1225 Main S104t
sebastlan, FL 3igii,
0lftce (772) 388.8215,br 388.8214
Ferx: (772) 589 -5570
FUNERAL HOME:
ADDRESS:
PHONE #: —1
(Cheek -One) Lot �81ock Unit �,
�.�PEN BURIAL LOT
,OPEN CREMAINS LOT Lot ,Block Unit
PEN COLUMBARIUM NICHE Niche Block ��nit
BURIAL DATE AND SERVICE TIME
_ W �j�
FOR DECEASED: Daa t l C-4-
Name
NAME AND SIGNATURE OF LOT OWNER OR REPRESENTATIVE:
(Must provide proper documentation of ownership)
Name
Qnalure Date
I certify that t have .determined the ownership of the above described 41te that all site fees and
administrative fees have been paid and authorize opening of s8MO
NAME AND SIGNATURE.OF LICENSED FUNERAL DIRECTOR � 1� l
nw-
_ ignature Dote
Name- --------- - - - - -- - - --------- - -• - -- ._....---- - - - - -- �..... . __...----- ......__- - - - - -• -- •....._.
Cemetery Sexton Certification:
1 certify that I have checked the ownership information ti by viewing the owner's deed and confirming
Clerk's office and th t e
8 3 //�
Cem ery ext n Date
This form to be provided to Clerk's Office by Sexton fcr permanent record upon completion.
A
FLORIDA DEPARTMENT OF
HEALT
(TYPE)
State of Florida, Department of Health, Vital Statistics
APPLICATION FOR BURIAL - TRANSIT PERMIT
1. Name of First Middle Last Date Month Day Year
Deceased of
DANIEL MEJIA Death 07 30 2010
2. Place of Death City, Town or Location Name of (If neither, give street address)
County p. or
INDIAN RIVER SEBASTIAN Hos Hos SEBASTIAN RIVER MEDICAL CENTER
3. Name of Medical Address Phone Number
Certifier MICHAEL A. VENAZIO, MD 8005 BAY ST, SUITE 1
Medical Examiner Physician SEBASTIAN FL 32958 772- 388 -2110
4. Name of Funeral Home /Direct Disposal Address Fla. Lic. No. /Reg. No, Phone No. (Area Code)
Establishment 735 S. FLEMING ST.
SEAWINDS FUNERAL HOME SEBASTIAN, FL 32958 41682 772- 589 -1933
5. Check a. The medical certification has been completed and signed. A completed certificate of death accompanies this
Appropriate application.
Box
b. ® DR. VENAZIO was contacted on 08/02/10
He /she verified that this death was from natural causes, that there was no accident nor other external cause of death,
and that HE will complete and sign the medical
certification of cause of death within 72 hours.
C. ❑ was contacted on He /she verified that
, Medical Examiner, will complete and sign the
medical certification of cause of death within 72 hours.
6. Funeral Director/ nature - F.E. No. /Reg. No. Date Signed
Direct--isposer FO 46789 08/02/10
B. BURIAL - TRANSIT PERMIT
Permission is hereby granted to dispose of this body. Permit No. 10- 41682 -129
Me; A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician has
been contacted by the funeral director and will not be able to complete the medical certification of cause -of -death section of the death certificate within
72 hours.
F] No extension of time f r filing t death rtificat has b n requested.
Registrar or Date Date Certificate
Subregistrar Signature` I Issued: 08/02/10 Dye: 08/13/10
C AUTHORIZATION for CREMATION, DISSECTION, or BURIAL -AT -SEA
Approval Number: Date
Medical Examiner, , gave authorization by telephone to
Funeral Director /Direct Disposer. Date
The Medical Examiner's approval must be obtained before disposal by any of the above methods. A waiting period of 48 hours after death is
required for all cremations.
D.
Method of Disposition:
XAIBURIAL
OCREMATION
Signature of Sexton
or Person -in- Charge
®STORAGE
®OTHER (Specify)
CEMETERY OR CREMATORY /—
Place of Disposition
Date of Disposition g /f�� Z)
This permit must be endorsed by the Sexton or person -in- charge (or by the Funeral Director /Direct Disposer wnen inere Is 11U Oc>«VI v — 1
within 10 days to the local County Health Department in the county where disposition occurred.
Distribution: white: Cemetery or Crematory
DH 326, 8/97 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer
(Stock Number: 5740- 000 -0326 -2) Pink: Local Registrar Re kd �5 P."
CITY OF SEEB
Certificate of Inte
IN ACCORDANCE with provisions of
Sebastian, it is hereby certified th
Rosa Zamarrita P 'ce
(name)
In and for consideration .f the sum of
rights in the SebasMianicipal Ceme
Certificate No. 2266
Code of; finances off#e City of
C,,,2, Fel e, FL 32948
(a )
)00.0 1ntitled to full interment
for the' ollowing lot:
Block 119 Lot 38
of a Se ba . cipal Cemetery,
aintai ' d on file In a records of the City Clerk
,4
for use in acc&N i " a„the conditions, ordinances, resolutions, rules and
regulations prescrib � fore by the City of Sebastian.
CONVEYED THIS 6t" day of August, 2010.
CITY OF SEBASTIAN, FLORIDA
Al Minner
City Manager
ATTEST:
ASally . Maio, MMC
It ity Clerk
i
Feb 13 2003 11143AM COS CEMETERY -
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